1. Molyneux, Jacob


Sustainable and equitable payment structures are urgently needed for this promising acute care model.


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Nurses like Mae Centeno, DNP, APRN, ACNS-BC, know that many patients, if given the choice, would rather be cared for at home, in contact with loved ones and familiar environments, than in the hospital. Centeno's parents are both in their 80s and have been patients at the health system where she works; she says that for a manageable acute condition, their preference (and hers for them) would be care in the home. This, says Centeno, chief nursing officer for virtual care delivery at Texas Health Resources, has given a personal impetus to her work on her health system's new hospital-at-home program, Texas Health Care at Home, which after months of preparation enrolled its first patients in September 2022.

Figure. Nurse Tami H... - Click to enlarge in new windowFigure. Nurse Tami Hampson and Dr. Vinay Shah from the in-home health care provider DispatchHealth arrive at a patient's Phoenix apartment for a medical visit. Photo by Katherine Davis-Young.

The hospital-at-home model, in which acute care patients receive hospital-level care in their homes through daily provider visits, telehealth, and remote monitoring, received a huge boost during the 2020 COVID-19 surges that filled hospitals to capacity and jump-started the use of telehealth across the health care system. Under the federal public health emergency, the Centers for Medicare and Medicaid Services (CMS) initiated a waiver allowing qualifying Acute Hospital Care at Home programs reimbursement for individual patients for the duration of the emergency and waiving the requirement for 24/7 nursing care. In response, as many as 257 qualifying hospitals in 37 states have begun programs.


The public health emergency is expected to end sometime in 2023, possibly as early as April. Despite enthusiasm for this model of care among hospitals and patients, proposed legislation to extend the Medicare waiver for two years is still pending at time of publication, and Medicare hasn't yet signaled that it will undertake a nationwide demonstration project to allow a number of programs to continue while collecting more information to inform policy. In the absence of reliable longer-term payment and regulatory structures to address important questions of equity, oversight, and sustainability, the postpandemic future of many U.S. hospital-at-home programs is uncertain.



Hospital at home has been well integrated into the health systems of countries such as Australia and France for decades. In the mid-1990s, Bruce Leff and colleagues at Johns Hopkins developed and piloted one of the early models in the United States. Because of the lack of a clear funding mechanism, until the pandemic this model had been used in only a limited way in the United States by the Veterans Administration, resource-rich hospital systems, and individual hospitals in partnership with private companies and as part of a CMS Health Care Innovation Awards project. Getting hospital-at-home programs up and running can be costly and time consuming, but the payoff is that they have consistently shown improved outcomes in patient mortality, 30-day readmission rates, infections, falls, delirium, and ED visits, as well as increased patient satisfaction and reduced costs of care.



Hospital at home should not be confused with home care, though some care tasks may overlap. Traditional home health nursing patients must meet discharge criteria; hospital-at-home patients meet inpatient acute care criteria, indicating that these patients are sicker and not yet well enough to be discharged. Requirements of the Medicare waiver ensure that each patient receives at least one daily visit by a physician, NP, or other advanced care provider (remote or in person), and at least two in-person nursing or paramedic visits daily. The rules of the waiver allow for a variety of staffing approaches by different programs.


Patients are often given tablets or other digital devices through which they can converse with nurses or physicians and, if needed, immediately contact a remote provider for help. Patients' vital signs can be remotely monitored, with the information regularly uploaded to their electronic health record (EHR). In addition, all hospital-at-home programs must be able to provide or contract for and coordinate multiple diagnostic and support services, including pharmacy, infusion, respiratory care, laboratories and radiology, food services, physical and occupational therapy, social work, and care coordination. A key challenge and expense for many programs is coordinating these services and integrating information from all providers and processes into the patient's EHR.



While Medicare has approved 60 conditions for treatment reimbursement under the waiver, most programs have started with a few conditions only, enrolling patients meeting certain criteria either directly from hospital EDs or from inpatient units. Typical conditions more easily managed in the home include heart failure, chronic obstructive pulmonary disease, pneumonia, cellulitis, gastroenteritis, nephritis, and complicated urinary tract infections. Conditions requiring intensive 24/7 monitoring and care, on the other hand, are unlikely to be a good match for the level of care provided in hospital at home.


Says Centeno, "We screen our patients from both a clinical and a social standpoint. . . . For what the patient needs, are we able to provide that level of care and services in the home? And then on the social side, we need to make sure that the home is safe, not just for the patient, but for the people who will be coming into the home."


Some patients prefer to stay in the hospital, or it may be determined that they would be safer and better off in the hospital environment. Notes Ab Brody, PhD, RN, GNP-BC, FAAN, an NP and professor of geriatric nursing at New York University, who has worked on and studied hospital-at-home programs for years, "There might be a loved one that's already at home caring for them, and this adds burden, which means they're more likely to want to take them to the hospital because the hospital is a reprieve." On the other hand, says Brody, some caregivers were "so thankful for that program because it enabled the patient to stay in their home-based environment."



Every hospital-at-home program will differ in its mix and use of providers and virtual versus in-person visits. Centeno says that what she looks for first in a nurse who will join the Texas Health Care at Home program is critical thinking. Most, she says, have ICU or medical-surgical experience, but many also have home care experience. Echoing this, Brody believes the jury is still out on the best skill set for a nurse in this care setting. Whether nurses have an acute care or home health background, he has found that there is "a need in both cases to learn new skills" because hospital at home "requires both home care and acute care competencies."


In addition, referring to the numbers of older nurses who left nursing during the pandemic, Centeno says that she hopes working in a Texas Health Resources program as a virtual care nurse in close contact with the care team and a set number of patients could provide experienced nurses with a less physically taxing option for continuing to work as nurses. Brody further develops this point in terms of the intense burnout and stress in nursing today: "I think more than a nurse staffing problem, we have a nurse environment problem. . . . There are opportunities in hospital at home for nurses who want different experiences than they've had."



Many nurses involved with hospital at home stress that they feel privileged to be guests in their patients' homes and gain deeper insight into factors that contribute to patients' health and well-being. "The truest form of patient-centered care is home-based care," says Brody. "Because the nurse is the one in the home, they're the one developing the rapport with the patient and family. They're the one seeing things and hearing things that no one else can hear." For example, a nurse might realize that a dietary service could improve a patient's health, or that elements of the setting are making a patient sicker.



As hospital at home joins hospice and other home-based care models already in wide use for an aging patient population, emerging abuses like fraud and shortcomings in care in these other areas point to the importance of well-designed oversight and payment structures. Some argue that hospital-at-home programs as currently reimbursed could open the door to "gaming the system," deepen inequities in some communities, and make more work for overburdened family caregivers. In a 2021 University of Pennsylvania Leonard Davis Institute of Health Economics panel that addressed this topic, hospital-at-home pioneer Bruce Leff suggested that hospitals of the future may be "big ERs, ORs, and ICUs," with "everything else . . . pushed out to the community." On the same panel, Meena Seshamani, current director of the Center for Medicare, emphasized that for a sustainable model of hospital at home we need to move away from the current fee-for-service model under the waiver to a value-based system; she also noted the importance of public-private partnerships. Taking up these challenges, physician and health care executive Reed Tuckson pointed out that services to support safe, quality hospital care at home simply don't exist in many communities. As the CMS looks to the future of hospital at home, he argued, we will need "payment models that integrate the social support system, rather than a 'piecemeal' arrangement."


It has been said that social determinants of health are no longer just abstractions when nurses and other providers see patients in their homes and communities. In a 2022 editorial in the Journal of the American Geriatrics Society, Brody and colleagues emphasized that some communities would need support with postacute care, starting hospital-at-home programs, and technology, and that such differences in resources should be factored into any long-term regulations and payment arrangements the CMS initiates.


The fate of proposed legislation to extend the CMS waiver two more years, or of a hoped-for CMS demonstration project to sustain current programs and gather more information on how to best support an effective, equitable, and sustainable hospital at home, remains unclear as 2023 gets underway.-Jacob Molyneux, senior editor